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Medical Dental History Form for Patients under Age 18PATIENTDate ______________Patient's Last name________________________First nameMiddle initial_____Prefers to Be Called ________________________ Hobbies, activities ___________________________________________Birth date_________________ Sex: MaleFemaleSocial Security # School _____________________________ Grade E-mail address (es) ____________________________________Home address ___________________________________________ City, State, Zip code _____________________________Home phone ( )-Cell phone ( )-PARENT/GUARDIANCustodial parent(s) name (s) _______________________________________________________________________________Patient lives with (check all that apply)motherfatherstepmotherstepfathergrandparent(s)Other ______________________________Father's full nameTitleMr.Dr.Other Occupation ___________________________Email address ___________________________________________________Address (if different) ______________________________________________________________________________________Home Phone (if different): ( )-Cell phone ( )-Work phone ( )-Mother's full nameTitleMrs.Ms.Dr.Other Occupation ____________________________ Email address _____________________________________________________Address (if different) ______________________________________________________________________________________Home Phone (if different): ( )-Cell phone ( )-Work phone ( )-DENTISTPatient’s Dentist ________________________________ Address, City, State _______________________________________Last seen ___________ Reason _________________________________________ Next appointment __________________Other dentists/dental specialists now being seen: Name ____________________________ City, State _________________Reason _________________________________________________________________________________________________GENERAL INFORMATIONWhat concerns you about your child’s teeth? __________________________________________________________________What concerns your child about his/her teeth? ________________________________________________________________How does your child feel about orthodontic treatment? _________________________________________________________Who suggested that your child might need orthodontic treatment? ________________________________________________Why did you select our office? _______________________________________________________________________________Describe any previous orthodontic treatment or consultations. ____________________________________________________Does your child play a musical instrument? Brother/sister nameage had orthodontic treatment?YesNoIf yes, where? ______________Brother/sister nameage had orthodontic treatment?YesNoIf yes, where? ______________Brother/sister nameage had orthodontic treatment?YesNoIf yes, where? ______________Brother/sister nameage had orthodontic treatment?YesNoIf yes, where? ______________Have any other family members been treated in this office? Please name them. _____________________________________FINANCIAL RESPONSIBILITYWho is financially responsible for this account?________________________________Address (if different from page 1) _______________________________________City, State, Zip __________________________Home phone ( )-Cell phone ( )-E-mail address (es) ____________________________Social Security # - - Employer: ______________________________________________________________Who will be responsible for bringing the patient to orthodontic appointments? ________________________________________DENTAL INSURANCEPrimary policy holder’s full name ____________________________ Birth date _________________Social Security # - - Relationship to patient __________________________Address and phone (if not listed above) _________________________________________________________________________Employer _____________________________ Address _____________________________________________________________Insurance company __________________________ Group # ____________________ ID # _______________________________Does this policy have orthodontic benefits?YesNoDon’t knowSecondary policy holder’s full name _________________________ Birth date __________________Social Security # - - Relationship to patient __________________________Address and phone (if not listed above) ________________________________________________________________________Employer _____________________________ Address ____________________________________________________________Insurance company __________________________ Group # _____________________ ID # ______________________________Does this policy have orthodontic benefits?YesNodon’t knowMEDICAL INSURANCEPolicy holder’s full name ___________________________________________Insurance company _______________________________________________PHYSICIANPatient’s Physician ____________________________ City, State _________________________________Last seen ____________ Reason ______________________________________________ Next appointment _____________Most recent physical exam __________________________Other physicians/health care providers being seen now:Name ______________________________ City, State ___________________________________Reason __________________________________________________________________________Name ______________________________ City, State ___________________________________Reason __________________________________________________________________________Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).MEDICAL HISTORYNow or in the past, has your child had?Yesnodk/u Birth defects or hereditary problems? Yesnodk/u Bone fractures, or major injuries? Yesnodk/u any injuries to face, head, and neck?Yesnodk/u Arthritis or joint problems?Yesnodk/u Cancer, tumor, radiation treatment or chemotherapy? Yesnodk/u Endocrine or thyroid problems?Yesnodk/u Diabetes or low sugar? Yesnodk/u Kidney problems?Yesnodk/u Immune system problems? Yesnodk/u History of osteoporosis?Yesnodk/u Gonorrhea, syphilis, herpes, and sexually transmitted diseases?Yesnodk/u AIDS or HIV positive?Yesnodk/u Hepatitis, jaundice or other liver problems?Yesnodk/u Polio, mononucleosis, tuberculosis, pneumonia? Yesnodk/u Seizures, fainting spells, neurologic problem? Yesnodk/u mental health disturbance or depression?Yesnodk/u History of eating disorder (anorexia, bulimia)? Yesnodk/u frequent headaches or migraines?Yesnodk/u High or low blood pressure?Yesnodk/u Excessive bleeding or bruising tendency, anemia?Yes no dk/u Chest pain, shortness of breath, tire easily, swollen ankles?Yes no dk/u Heart defects, heart murmur, and rheumatic heart disease? Yes no dk/u Angina, arteriosclerosis, stroke or heart attack?Yes no dk/u Skin disorder (other than common acne)? Yes no dk/u Does your child eat a well-balanced diet? Yes no dk/u Vision, hearing, or speech problems?Yes no dk/u frequent ear infections, colds, throat infections? Yes no dk/u Asthma, sinus problems, and hay fever?Yes no dk/u Tonsil or adenoid condition?Yes no dk/u does your child frequently breathe through his/her mouth?Yesnodk/u has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?Yesnodk/u has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?Has your child had allergies or reactions to any of the following?yesnodk/uLocal anesthetics (novocaine, lidocaine, xylocaine)yesnodk/uLatex (gloves, balloons)yesnodk/uAspirinyesnodk/uIbuprofen (Motrin, Advil)yesnodk/uPenicillinyesnodk/uOther antibioticsyesnodk/uMetals (jewelry, clothing snaps)yesnodk/uAcrylicsyesnodk/uPlant pollensyesnodk/uAnimalsyesnodk/uFoodsyesnodk/uOther substancesDENTAL HISTORYyesnodk/uErupting teeth very early or very late?yesnodk/uPrimary (baby) teeth removed that were not loose?yesnodk/uPermanent or extra (supernumerary) teeth removed?yesnodk/uSupernumerary (extra) or congenitally missing teeth?yesnodk/uChipped or injured primary or permanent teeth?yesnodk/uAny sensitive or sore teeth?yesnodk/uAny lost or broken fillings?yesnodk/uJaw fractures, cysts, infections?yesnodk/uAny teeth treated with root canals or pulpotomies?yesnodk/uFrequent canker sores or cold sores?yesnodk/uHistory of speech problems or speech therapy?yesnodk/uDifficulty breathing through nose?yesnodk/uMouth breathing habit or snoring at night?yesnodk/uHistory of speech problems?yesnodk/uFrequent oral habits (sucking finger, chewing pen, etc.)?yesnodk/uTeeth causing irritation to lip, cheek or gums?yesnodk/uTooth grinding or clenching?yesnodk/ uClicking, locking in jaw joints?yesnodk/uSoreness in jaw muscles or face muscles?yesnodk/uHas your child been treated for “TMJ” or “TMD”Problems?yesnodk/uAny broken or missing fillings?yesnodk/uAny serious trouble associated with previous dental treatment?yesnodk/uHas your child ever been diagnosed with gum disease or pyorrhea?Now or in the past, has the patient had:PATIENT HEALTH INFORMATIONDo you think that any of your child’s activities affect his/her face, teeth or jaws? How? _________________________________List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.Medication _____________________________ Taken for _____________________________________Medication _____________________________ Taken for _____________________________________Medication _____________________________Taken for ______________________________________Do you take antibiotic pre-medication before any dental procedures?YesNo Does the patient currently have (or ever had) a substance abuse problem? Does your child chew or smoke tobacco? Have you noticed any unusual changes in your child’s face or jaws? Any other physical problems? FAMILY MEDICAL HISTORYHave the parents or siblings ever had any of the following health problems? If so, please explain.Bleeding disorders ________________________________________________Diabetes _________________________________________________________Arthritis __________________________________________________________Severe allergies ___________________________________________________Unusual dental problems ___________________________________________Jaw size imbalance ________________________________________________Other family medical conditions? ____________________________________How often does your child brush? ____________________________________Floss? ___________________________________________________________RELEASE AND WAIVERI authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurancecompany.Parent/Guardian Signature ____________________________________________________________Date____________________________I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.Parent/Guardian Signature ____________________________________________________________Date____________________________MEDICAL HISTORY UPDATESChanges ______________________________________Parent/Guardian Signature ____________________________________________________ Date____________________________Dental Staff Signature ________________________________________________________Date____________________________Changes ______________________________________Parent/Guardian Signature ____________________________________________________ Date____________________________Dental Staff Signature ________________________________________________________Date____________________________Changes ______________________________________Parent/Guardian Signature ____________________________________________________ Date____________________________Dental Staff Signature ________________________________________________________Date____________________________ ................
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